A young man came to our office concerned that he was going to be terminated from his job, because he couldn’t stay awake at work. He would fall asleep in the middle of typing documents and wake with pages full of gibberish. He had difficulty driving home in the evenings and was afraid he was going to cause a major accident. His home life was suffering as well — he would often find himself falling asleep in the middle of conversations with his wife.
This patient had narcolepsy, which probably started in his early twenties. He remembers having difficulty in college staying awake in his classes, especially ones that he considered boring. He reported drinking large amounts of caffeine but still had trouble staying awake.
About one in 2,000 patients have narcolepsy. Patients with narcolepsy are frequently misdiagnosed, as symptoms often start in adolescence when young adults are known for their terrible sleep hygiene. There can be as many as 10 years between symptom onset and diagnosis. One of the first symptoms is daytime sleepiness, but as the illness progresses, patients may experience cataplexy, hypnagogic hallucinations, sleep paralysis, blurred vision and memory lapses.
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Patients with narcolepsy have low levels of hypocretin, a chemical found in the brain that helps maintain wakefulness. Narcolepsy occurs in families, raising concerns about the possibility of genetic abnormalities. There are also studies that point to a possible autoimmune connection. At least one study has shown that streptococcal infections may trigger narcolepsy.
Performing overnight polysomnogram with multiple sleep latency tests is the basis of diagnosis. The polysomnogram will rule out other causes of sleepiness, including sleep apnea and periodic limb movement disorder. The multiple sleep latency test is performed during normal daytime wakeful hours and consists of a series of naps that measure how quickly the patient falls asleep, and if the patient experiences REM sleep.
Treatment includes stimulant therapy with medications including modafinil, armodafinil, methylphenidate and dextroamphetamine. Antidepressants are used to treat the hypnagogic hallucinations, sleep paralysis and cataplexy. Behavioral therapy and sleep hygiene are stressed. Patients are also encouraged to take short naps if possible.
Consider narcolepsy in young adults who have a difficult time staying awake especially if their sleepiness is interfering with their social life and ability to work. In my next blog, I will discuss further the interesting symptom of cataplexy, which is often seen in the narcoleptic patient.
Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.
